Effect of subgingival irrigation with chlorhexidine as an adjunct to non-surgical periodontal therapy around banded first molars in orthodontic patients: A randomized clinical trial

Abstract

Aim: Banding molars for anchorage may cause periodontal inflammation due to various reasons. To maintain a reasonably good periodontal status during orthodontic treatment, adequate oral hygiene maintenance measures should be followed and monitored. Hence, the aim of this study was to evaluate the effect of non-surgical periodontal therapy on the first molars banded for fixed orthodontic treatment. Materials and Methods: A double-blinded randomized clinical trial including 35 patients scheduled for fixed orthodontic treatment was recruited, from which, 32 patients with banded first molars were divided into Group A and Group B with 16 patients each. Both the groups underwent routine full-mouth supragingival and subgingival scaling around all banded first molars. Group B also underwent subgingival irrigation with 0.2% chlorhexidine gluconate solution around the banded first molars. Treatment for both the groups was performed at the 3rd, 6th, and 9th month. Full-mouth plaque index (PI) and gingival index, probing pocket depth (PPD), and clinical attachment level (CAL) of each banded first molar were recorded at baseline, 6th month, and 12th month. Alveolar crestal bone level around each banded first molar was assessed radiographically at baseline and 12th month. Results: Intragroup comparison showed significant reduction in PI and Group B showed a significant increase in PPD and CAL from 0 day to 12th month. However, intergroup comparison did not show a significant difference in clinical parameters and radiographic crestal bone level. Conclusion: The use of 0.2% chlorhexidine gluconate solution showed no significant benefit on the banded molars as compared to scaling alone.

Full text

Drug Invention Today | Vol 11 • Issue 8 • 2019
1750
Effect of subgingival irrigation with chlorhexidine as
an adjunct to non-surgical periodontal therapy around
banded first molars in orthodontic patients: A randomized
clinical trial
Nashra Kareem1*, Jaideep Mahendra2, Anil Kumar Kanakamedala2, Nayeemullah Khan3, Arani
Nandakumar3, Ambalavanan Namasivayam2
INTRODUCTION
The use of orthodontic bands around molars for
anchorage is a common practice in fixed orthodontic
treatment. However, unfavorable or excessive forces
may affect the periodontium by causing periodontal
inflammation due to numerous reasons such as
chemical irritation caused by the cement used to
retain the band, mechanical irritation of the gingival
tissues due to subgingival placement of the bands,
food impaction, and plaque retention. Furthermore,
patients undergoing orthodontic treatment may
have a tendency to clean their anterior teeth more
effectively than their posterior teeth. Plaque control
Research Article
1Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences,
Saveetha University, Chennai, Tamil Nadu, India,2 Department of Periodontics, Faculty of Dentistry, Meenakshi Academy
of Higher Education & Research, Chennai, Tamil Nadu, India,3 Department of Orthodontics & Dentofacial Orthopaedics,
Faculty of Dentistry, Meenakshi Academy of Higher Higher Education & Research, Chennai,Tamil Nadu, India.
*Corresponding author: Nashra Kareem, Department of Periodontics, Saveetha Dental College and Hospitals, Saveetha
Institute of Medical and Technical Sciences, Saveetha University, 162, Poonamallee High Road, Velappanchavadi,
Chennai - 600 077, Tamil Nadu, India. E-mail: periodontistnashra@gmail.com
Received on: 15-01-2019; Revised on: 22-02-2019; Accepted on: 16-03-2019
Access this article online
Website: jprsolutions.info ISSN: 0975-7619
is, therefore, very difficult in patients with fixed
orthodontic appliances.[1] The sites reported to be the
most severely affected are interproximal areas of the
posterior teeth.[2]
Attempts to prevent gingivitis and periodontitis by
mechanical plaque control measure have only been
partially successful. To accomplish complete plaque
removal, non-surgical periodontal therapy (NSPT)
with various adjunctive treatment modalities such as
chemical plaque control agents has been successfully
used.[3]
Chlorhexidine is the gold standard, most commonly
used and recognized as the primary agent for chemical
plaque control due to its bacteriostatic and bactericidal
activity, high substantivity, and broad-spectrum
action. Subgingival irrigation using chlorhexidine
solution, either by single or continual applications over
ABSTRACT
Aim: Banding molars for anchorage may cause periodontal inflammation due to various reasons. To maintain a reasonably
good periodontal status during orthodontic treatment, adequate oral hygiene maintenance measures should be followed and
monitored. Hence, the aim of this study was to evaluate the effect of non-surgical periodontal therapy on the first molars
banded for fixed orthodontic treatment. Materials and Methods: A double-blinded randomized clinical trial including
35 patients scheduled for fixed orthodontic treatment was recruited, from which, 32 patients with banded first molars were
divided into Group A and Group B with 16 patients each. Both the groups underwent routine full-mouth supragingival and
subgingival scaling around all banded first molars. Group B also underwent subgingival irrigation with 0.2% chlorhexidine
gluconate solution around the banded first molars. Treatment for both the groups was performed at the 3rd, 6th, and 9th month.
Full-mouth plaque index (PI) and gingival index, probing pocket depth (PPD), and clinical attachment level (CAL) of each
banded first molar were recorded at baseline, 6th month, and 12th month. Alveolar crestal bone level around each banded first
molar was assessed radiographically at baseline and 12th month. Results: Intragroup comparison showed significant reduction
in PI and Group B showed a significant increase in PPD and CAL from 0 day to 12th month. However, intergroup comparison
did not show a significant difference in clinical parameters and radiographic crestal bone level. Conclusion: The use of 0.2%
chlorhexidine gluconate solution showed no significant benefit on the banded molars as compared to scaling alone.
KEY WORDS: Gingivitis, Molar, Periodontitis

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varying time periods, has been reported to effectively
reduce gingival and periodontal inflammation.[2,4]
Hence, the rationale of the study was to clinically
and radiographically assess the periodontal status
of banded first molars by the periodic use of
chlorhexidine irrigation in patients undergoing fixed
orthodontic treatment.
Therefore, the aim of this study was to evaluate the
effect of NSPT on the periodontal status around the
first molars banded for fixed orthodontic treatment.
MATERIALS AND METHODS
Thirty-five patients, scheduled to undergo fixed
orthodontic treatment, were recruited, of which,
thirty-two patients with banded first molars were
selected for the study. The study was approved by the
“Meenakshi Institutional Review Board” (MADC/
IRB-IX/2016/153). Both systemically healthy
male and female patients within the age group of
16–25 years, diagnosed with malocclusion, undergoing
fixed orthodontic treatment, and having banded first
molars were included in the study. Those patients with
congenital malformations in the oral cavity, history
of periodontal therapy within the previous 6 months,
using removable orthodontic appliances, under
medication, and smokers were excluded from the
study. Computer-generated randomization was done
for the allocation of the groups and the participants
were divided into Group A (control group) and Group
B (test group). The sample size for the study was
calculated and power analysis was done. The power of
the study was 90%, with a sample size of 16 patients
in each group [Figure 1].
The study was explained to the patients and a written
informed consent was obtained from those who agreed
to voluntarily participate in this study. The study was
conducted from April 2016 to August 2017 at the
Faculty of Dentistry, Meenakshi Academy of Higher
Education and Research, Chennai (Clinicaltrials.gov
identifier: NCT03410602).
Figure 1: CONSORT flow diagram

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Pre-treatment Procedure
Supragingival scaling was done for each patient
1 week before orthodontic treatment. Oral hygiene
instructions were given and patients were motivated
to maintain good plaque control [Table 1].
Protocol for Baseline (0 Day) – On the day of Band
Placement
Study design and recording of periodontal parameters
A double-blinded, randomized clinical trial study
was designed. Clinical periodontal examination and
the treatment procedures were performed by two
trained and calibrated investigators (NK and JM) who
were masked to the study groups. Overall, k value
for intraexaminer reliability was 0.69. Periodontal
parameters such as full-mouth plaque index (PI)[5] and
gingival index (GI),[6] probing pocket depth (PPD),
clinical attachment level (CAL),[7] and radiographic
evidence of alveolar crestal bone level were measured
around each banded first molar for both the groups
after the placement of orthodontic bands.
Radiographic assessment of alveolar crestal bone level in
Group A and Group B
Digital radiographic images were obtained with the
paralleling technique using DIGORA Soredex® and
photostimulable phosphor imaging plate. In this
technique, the imaging plate was placed in a holder and
positioned in the mouth parallel to the long axis of the
tooth to standardize the procedure. The film holder was
used with standard X-ray tubehead positions. The digital
images acquired were assessed using CorelDRAW®
(Corel Corporation). Alveolar crestal bone level changes
on the mesial and the distal aspect of the banded first
molars of both the groups were estimated. This was
noted as the vertical distance (mm) from the lowest
point of the band to the crest of the alveolar bone.
3rd month Protocol for Group A and Group B
Both the groups underwent the following treatment at
the 3rd month.
Group A (control group): Routine full-mouth
supragingival and subgingival scaling was done
around all the banded first molars.
Group B (test group): Routine full-mouth
supragingival and subgingival scaling was done for
all the banded first molars followed by irrigation with
0.2% chlorhexidine gluconate solution.
Irrigation Protocol for Group B
For the test group, after subgingival scaling, the
banded first molars were isolated with cotton rolls and
air-dried. The mesiobuccal, midbuccal, distobuccal,
mesiolingual, midlingual, and distolingual areas of the
teeth were then subjected to continuous subgingival
irrigation of 0.2% chlorhexidine gluconate solution
(HEXIDINE®) using a 2 ml disposable syringe.
Subgingival irrigation was done at each of the six sites
for 5 s by slowly releasing the irrigation fluid into each
pocket with only little pressure and gentle movements
applied. Excess irrigant solution was continuously
aspirated with the help of a suction device. Following
irrigation, the patients were instructed not to rinse, eat,
or drink thereafter for the next 20 min.[1]
6th Month Protocol for Group A and Group B
For both the groups, recording of the periodontal
parameters: PI, GI, PPD, and CAL were assessed and
followed by the same treatment protocol as done on
the 3rd month. However, one patient in each group
discontinued the treatment, and hence, 15 patients in
each group were analyzed further for the 9th month
protocol.
9th Month Protocol for Group A and Group B
Both the groups underwent the same treatment
protocol as done on the 3rd month and 6th month.
12th Month Protocol for Both Groups
For both the groups, reexamination of the periodontal
parameters: PI, GI, PPD, CAL, and radiographic
assessment of alveolar crestal bone level were recorded.
Statistics
The collected data were analyzed with IBM SPSS
statistics software 23.0 Version. To describe about the
data descriptive statistics, mean and standard deviation
were used. The test of normality with Shapiro-Wilk test
showed that the data were normally distributed. Hence,
to find the significant difference between the bivariate
samples in independent groups (Group A and Group
B), the independent samples t-test was used. For the
multivariate analysis within groups, PI, GI, PPD, and
CAL values were compared between baseline (0 day),
6th month, and 12th month using the repeated measures
ANOVA. The alveolar crestal bone values were
compared between baseline (0 day) and 12th month using
the paired sample t-test. In the above statistical tool, P =
0.05 is considered as statistically significant level.
RESULTS
On comparing the mean PI from 0 day to 6th month and 0
day to 12th month, Group A showed a significant change
of 0.57 ± 0.24 (P = 0.0001) and 0.75 ± 0.19 (P = 0.0001),
respectively, whereas Group B showed a change of
0.43 ± 0.54 (P = 0.02) and 0.77 ± 0.25 (P = 0.0001),
respectively. On comparing the mean changes between
the groups, Group B showed more reduction compared
to Group A, but it was statistically insignificant [Table 2].
On comparing the mean GI from 0 day to 6th month
and 0 day to 12th month, Group A showed a change

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Table 2: Comparison of mean, standard deviation and test of significance of Plaque Index and Gingival Index within
and between the groups at different time intervals.
Time interval Group A
(Mean±SD)
Group B
(Mean±SD)
P-value
(Between groups)
PI GI PI GI PI GI
0 day 1.01±0.3 1.19±0.97 0.94±0.24 0.93±0.55 0.24 (NS) 0.83 (NS)
6th month 0.44±0.25 1.25±0.21 0.5±0.52 1.20±0.42 0.69 (NS) 0.57 (NS)
12th month 0.26±0.2 1.17±0.15 0.17±0.12 0.93±0.53 0.12 (NS) 0.09 (NS)
Mean change 0 day to 6th month 0.57±0.24 –0.06±0.26 0.43±0.54 –0.25±0.56 0.81 (NS) 0.46 (NS)
P-value 0.0001 (S) 1.0 (NS) 0.021 (S) 0.32 (NS)
Mean change 0 day to 12th month 0.75±0.19 0.02±0.17 0.77±0.25 0.009±0.5 0.61 (NS) 0.30 (NS)
P-value 0.0001 (S) 1.0 (NS) 0.0001 (S) 1.0 (NS)
Mean change 6th month to 12th month 0.18±0.22 0.08±0.23 0.33±0.46 0.24±0.48 0.83 (NS) 0.41 (NS)
P-value 0.02 (S) 0.53 (NS) 0.04 (S) 0.15 (NS)
S - Statistically significant,NS - Statistically not significant,Level of significance P ≤ 0.05,PI – Plaque index,GI – Gingival index
Table 1: Study protocol
Time Protocol
1 week prior to orthodontic treatment Oral prophylaxis
Baseline (0 day) Recording of periodontal parameters & radiographic assessment for both the
groups immediately after band placement
3rd month Treatment for both the groups
Group A: Full-mouth supragingival scaling & subgingival scaling only around all
the banded first molars
Group B: Full-mouth supragingival scaling & subgingival scaling+irrigation only
around all the banded first molars
6th month Recording of periodontal parameters and treatment for both the groups
Group A: Full-mouth supragingival scaling & subgingival scaling only around all
the banded first molars
Group B: Full-mouth supragingival scaling & subgingival scaling+irrigation only
around all the banded first molars
9th month Same protocol followed as done at 3rd month
12th month Recording of periodontal parameters with radiographic assessment in both the
groups
of −0.06 ± 0.26 (P = 1.0) and 0.02 ± 0.17 (P = 1.0),
respectively, whereas Group B showed a change of
−0.25 ± 0.56 (P = 0.32) and 0.009 ± 0.5 (P = 1.0),
respectively, which was insignificant. However, on
comparing the mean changes between the groups,
Group B showed more reduction compared to Group
A though it was not significant [Table 2].
The mean PPD and CAL values were found to be the
same as there was no gingival recession or inflammation
noted in the teeth examined. On comparing the mean
PPD and CAL from 0 day to 6th month and 0 day to
12th month, Group A showed an insignificant change
of −0.31 ± 0.57 mm (P = 0.14) and −0.38 ± 0.66 mm
(P = 0.12), respectively, whereas Group B showed
a significant change of −0.2 ± 0.67 mm (P = 0.8)
and −0.48 ± 0.43 mm (P = 0.002), respectively. On
comparing the mean changes between the groups, it
was found to be insignificant [Table 3].
On comparing the mean alveolar crestal bone level
mesially from 0 day to 12th month, Group A showed a
change of −0.1 ± 0.95 (P = 0.67) and Group B showed
a change of −0.19 ± 0.81 mm (P = 0.36) which was
statistically insignificant. When the mean changes
were compared between the groups, it was also found
to be insignificant [Table 4].
On comparing the mean alveolar crestal bone level
distally from 0 day to 12th month, Group A showed
a change of 0.13 ± 0.73 mm (P = 0.49) and Group
B showed a change of −0.09 ± 1.01 mm (P = 0.71)
which was statistically insignificant. When the mean
changes were compared between the groups, it was
found to be insignificant [Table 4].
DISCUSSION
In the past, studies have compared the use of bands
or bonds on molars and have demonstrated greater
periodontal inflammation associated with bands.[8-10]
Huser et al. (1990) in their study analyzed the effects
of orthodontic bands on microbiological and clinical
parameters.[11] There was an increase in the PI and
bleeding scores of banded teeth and the placement of
orthodontic bands was associated with the establishment
of microorganisms usually found in periodontal diseases.
The use of subgingival irrigation of chlorhexidine as
an antiplaque agent has been previously demonstrated

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Table 3: Comparison of mean, standard deviation and test of significance of Probing Pocket Depth and Clinical
Attachment Level within and between the groups at different time intervals
Time interval Group A
(Mean±SD in mm)
Group B
(Mean±SD in mm)
P-value
(Between groups)
PPD CAL PPD CAL PPD CAL
0 day 3.02±0.5 3.02±0.5 3±0.7 3±0.7 0.94 (NS) 0.94 (NS)
6th month 3.33±0.4 3.33±0.4 3.2±0.64 3.2±0.64 0.49 (NS) 0.49 (NS)
12th month 3.4±0.54 3.4±0.54 3.5±0.82 3.5±0.82 0.74 (NS) 0.74 (NS)
Mean change 0 day to 6th month –0.31±0.57 –0.31±0.57 –0.2±0.67 –0.2±0.67 0.52 (NS) 0.52 (NS)
P-value 0.14 (NS) 0.14 (NS) 0.8 (NS) 0.8 (NS)
Mean change 0 day to 12th month –0.38±0.66 –0.38±0.66 –0.48±0.43 –0.48±0.43 0.48 (NS) 0.48 (NS)
P-value 0.12 (NS) 0.12 (NS) 0.002 (S) 0.002 (S)
Mean change 6th month to 12th month –0.06±0.71 –0.06±0.71 –0.28±0.8 –0.28±0.8 0.34 (NS) 0.34 (NS)
P-value 1.0 (NS) 1.0 (NS) 0.56 (NS) 0.56 (NS)
PPD - Probing Pocket Depth,CAL - Clinical Attachment Level,S - Statistically significant|NS - Statistically not significant,Level of significance P≤0.05
Table 4: Comparison of mean, standard deviation and test of significance of alveolar crestal bone level mesially and
distally within and between the groups at different time intervals
Time interval Group A
(Mean±SD in mm)
Group B
(Mean±SD in mm)
P-value
(Between groups)
Mesial Distal Mesial Distal Mesial Distal
0 day 1.73±0.83 2.11±0.65 1.81±0.92 2.43±0.84 0.8 (NS) 0.8 (NS)
12th month 1.84±0.82 1.99±0.84 2.0±0.76 2.53±0.8 0.56 (NS) 0.56 (NS)
Mean change 0 day to 12th month –0.1±0.95 0.13±0.73 –0.19±0.81 –0.09±1.01 0.72 (NS) 0.45 (NS)
p-value 0.67 (NS) 0.49 (NS) 0.36 (NS) 0.71 (NS)
S - Statistically significant NS - Statistically not significant,Level of significance P≤0.05
who stated that the probable mechanism for reduction
of plaque accumulation associated with subgingival
irrigation may be due to the reduction of specific
microorganisms or toxic products of plaque, or by
a disarrangement of subgingival plaque rather than
an instantaneous killing of microorganisms and this
could be possible if subgingival irrigation is carried
out several times at regular intervals.[12,13]
When both the groups were compared for mean GI in
our study, Group B showed more reduction compared
to Group A, but it was statistically insignificant.
This was in accordance with the study conducted
by Wennström et al. (1987), who also could not
show significant therapeutic benefit with the use
of chlorhexidine gluconate solution as an irrigating
agent along with mechanical debridement in reducing
gingival inflammation.[14]
Our study showed insignificant reduction in PI and GI
between the groups, probably because the mechanical
plaque control measures were equally effective
in reducing plaque accumulation and gingival
inflammation when compared to mechanical plaque
control along with chlorhexidine irrigation.
Intragroup comparison showed a higher reduction of
PPD and CAL in Group B from 0 day to 12th month.
When both the groups were compared for mean
PPD and CAL, there was no significant difference
noted. This was in accordance with the studies done
by MacAlpine et al. (1985) and Wennström et al.
in orthodontic patients. Morrow et al. (1992)
evaluated the effect of a single subgingival irrigation
using 0.12% chlorhexidine in adolescent orthodontic
patients with gingivitis and noted no marked decrease
in PI or pocket depth.[2] On the other hand, Babay and
Al Jasser (1996) examined adolescent patients for the
effect of a single application of 0.2% chlorhexidine or
sanguinarine delivered subgingivally around banded
first molars. The results revealed that subgingival
irrigation implemented every month, successfully
improved the gingival condition in adolescent patients
undergoing orthodontic treatment.[1]
NSPT has shown varied results in terms of periodontal
maintenance in orthodontic patients. Moreover, a fair
number of studies have evaluated the periodontal
status of banded first molars in fixed orthodontic
treatment. However, no previous study exists on
the effect of periodic NSPT on first molars banded
for fixed orthodontic treatment with clinical and
radiographic assessment.
Therefore, the aim of this study was to evaluate the
effect of NSPT on the periodontal status around first
molars banded for fixed orthodontic treatment.
In our study, when the mean PI was evaluated at
different time intervals, both the groups showed
a significant reduction. However, on comparison
between the groups, it was statistically insignificant.
These findings are consistent with the studies done by
Flemmig et al. (1990) and Schlagenhauf et al. (1990)

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(1987).[4,14] The increase in mean PPD in Group B
could be attributed to the presence of active orthodontic
treatment. The use of bands around the first molars
could have possibly overpowered the effect of
chlorhexidine ultimately causing an increase in mean
PPD. The exact mechanism is yet to be investigated.
Nelson and Artun (1997) stated that tilting or intrusion
of teeth may cause a shift of the supragingival band to
a subgingival position, leading to bone and attachment
loss.[15]
When both the groups were compared for mean
alveolar crestal bone level mesially, it showed an
increase in alveolar bone loss from 0 day to 12th month.
This is harmonious with the study done by Jatin et al.
who indicated loss of interproximal alveolar bone
during orthodontic treatment.[16]
The probable explanation for increase in alveolar
crestal bone loss irrespective of whether the banded
molars were subjected to subgingival scaling with and
without chlorhexidine irrigation is due to orthodontic
forces applied that create pressure and tension sites in
the periodontal ligament on either side. Compression
of the periodontal ligament on the pressure side
leads to increase in vascularity and formation of
osteoclasts that ultimately cause bone resorption.
Furthermore, various studies have demonstrated
that tooth movements providing a high load at the
alveolar crest, such as torque and rapid tipping, may
result in reduction of the height of alveolar crest.[17-19]
In addition, Boyd and Baumrind (1992) stated that
greater bone loss has been owed to more subgingival
placement of molar bands and due to lesser clinical
crown height in adolescents.[8]
Collected data and subjective observation indicated
that subgingival scaling with and without chlorhexidine
irrigation did not show significant improvement in
terms of PPD, CAL, and alveolar crestal bone level.
However, there was a significant reduction in PI in
both the groups from 0 day to 12th month perhaps
because all patients received regular reinforcement
of instructions in plaque removal. The GI remained
more or less unchanged even after subgingival
scaling and irrigation. The increase in PPD, clinical
attachment loss, and alveolar crestal bone level in both
the groups from 0 day to 12th month could be ascribed
to the presence of active orthodontic forces that
cause periodontal destruction. Other reasons include
mechanical irritation due to subgingival placement
of orthodontic bands, chemical irritation due to the
cement used to retain the bands, and food impaction
in the retentive areas of the orthodontic bands.
The limitation of the study was that the patients were
followed up for a year and not throughout the course
of their orthodontic treatment until the molars were
debanded. It would be more optimal to assess the
periodontal status before and after the placement of
orthodontic bands.
Therefore, this study clinically implicates that
adequate oral hygiene measures at regular intervals
with proper periodontal maintenance is required in
patients with fixed orthodontics to maintain a healthy
periodontium throughout the orthodontic treatment.
CONCLUSION
On a long-term basis of fixed orthodontic treatment
over a period of 1 year, the use of 0.2% chlorhexidine
gluconate solution showed no significant benefit.
Furthermore, extensive studies with larger sample size
and longer duration may be needed to elucidate the use
of chlorhexidine gluconate solution as an antiplaque
and anti-inflammatory agent with subgingival scaling
on patients undergoing fixed orthodontic treatment.
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Source of support: Nil; Conflict of interest: None Declared
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